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MA08.137d, Intravenous Ketamine (Ketalar®) and Intranasal Esketamine (Spravato®)
Effective date
Dec 29, 2025
Identified
Jun 19, 2026
Summary
Independence Blue Cross Medicare Advantage updated MA08.137d to MA08.137e, adding coverage for esketamine (Spravato) nasal spray as monotherapy for treatment-resistant major depressive disorder after inadequate response to two oral antidepressants, while clarifying that ketamine for acute/chronic pain and concurrent ketamine-esketamine use remain non-covered experimental/investigational treatments. The policy became effective 12/29/2025 with a note that missing language was added on 02/10/2026.
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What to do
Action · 6 steps
01By 12/29/2025, billing team must: 1) Update claims processing system to recognize G2082 and G2083 as covered HCPCS codes for esketamine administration with physician/QHP supervision and 2+ hours post-administration observation.
022) Configure system to require ICD-10 diagnosis codes F32.0, F32.1, F32.2, F32.4, F32.5, F32.89, F33.0, F33.1 (and other listed MDD codes) for esketamine claims.
033) Add prior authorization workflow requiring documentation of: DSM-5-TR MDD criteria, severe depression per validated scale (BDI-II, MADRS, PHQ-9, HAM-D), inadequate response (<25% improvement) to at least 2 different FDA-approved antidepressants from different classes at adequate dose/duration (≥6 weeks, ≥80% adherence), and treatment-resistant depression status.
044) Flag and deny all claims for ketamine (Ketalar) for pain management and all concurrent ketamine-esketamine claims as non-covered experimental/investigational.
055) Keep CPT 99499 available for off-label esketamine observation coding.
06Providers and clinical staff should be notified that coverage now exists for esketamine monotherapy MDD treatment; failure to obtain proper prior authorization and documentation will result in claim denials.
Codes mentioned
99499G2082G2083F32.0F32.1F32.2F32.4F32.5F32.89F33.0F33.1
Original notice
MA08.137d, Intravenous Ketamine (Ketalar®) and Intranasal Esketamine (Spravato®)
medpolicy.ibx.com · Always check the source before changing claims.
Related changes
See all Independence Blue Cross changes →08.01.80e, Intravenous Ketamine (Ketalar®) and Intranasal Esketamine (Spravato®)HighEffective Jan 1, 2026 · Pharmacy08.01.80d, Intravenous Ketamine (Ketalar®) and Intranasal Esketamine (Spravato®)MediumEffective Dec 29, 2025 · Pharmacy08.01.80e, Intravenous Ketamine (Ketalar®) and Intranasal Esketamine (Spravato®)HighEffective Jan 1, 2026 · PharmacyMA08.137e, Intravenous Ketamine (Ketalar®) and Intranasal Esketamine (Spravato®)HighEffective Jan 1, 2026 · PharmacyBrowse every Independence Blue Cross change in the policy list